Vitiligo: can new treatments really repigment the skin?

Summary

Vitiligo is an autoimmune disease that appears as patches of skin depigmentation, and sometimes of hair. It affects 1-2% of the population and remains, even today, a stigmatising condition that is often poorly managed.

For a long time, patients were told there was "nothing to be done". That message is changing. A genuine therapeutic revolution is under way, driven in particular by a new molecule, ruxolitinib (Opzelura), the first specific treatment for vitiligo, which enables melanocytes to recolonise the skin and restore its colour.

What is vitiligo?

Vitiligo is an autoimmune dermatological disease defined by patches of skin depigmentation. It affects 1-2% of the general population and can appear on any area of the body: face, hands, feet, trunk, genitals. It is not life-threatening, but it can seriously affect quality of life.

Its social impact remains major in some contexts. As the French Vitiligo Association noted in 2024, the disease can be a source of discrimination: in some countries it is an obstacle to marriage, or even a cause of rejection. Public figures, such as the Canadian model Winnie Harlow, are helping to change how the disease is perceived.

Persistent misconceptions

For too long, mistaken beliefs led to inadequate care. They must be clearly corrected:

• "There is nothing to be done": false. Several treatment options exist, and new ones are arriving.
• "You must avoid the sun": this needs nuance. Controlled exposure can actually be part of care (medical UVB phototherapy, not to be confused with cosmetic UVA).
• "It is psychosomatic, all in the head": false. Vitiligo is a real autoimmune disease, linked to the destruction of melanocytes.
• "It is contagious": completely false. Vitiligo is not transmissible.

A study led in 2023 by Prof. Khaled Ezzedine (Henri-Mondor hospital, Créteil) revealed the scale of the problem: more than 80% of the patients surveyed had been offered no treatment at all.

An autoimmune mechanism

We now know that vitiligo is linked to a dysfunction of the immune system, leading to the loss of melanocytes, the cells that produce melanin, the skin's natural pigment.

About fifty genes (HLA, CTLA4, NLRP1, TYR…) are associated with vitiligo, but the disease is not hereditary in the strict sense. There is a genetic predisposition on which external factors trigger the autoimmune process that destroys melanocytes. These factors are linked to the exposome, that is, the set of exposures to which the body is subjected throughout life.

Which factors can trigger the disease?

In a predisposed person, a "stress" in the medical sense can set the process in motion. The list of possible triggers is long:

• surgery;
• an infection;
• hormonal changes (pregnancy, puberty, menopause);
• psychological stress;
• repeated friction on the skin;
• a burn, such as sunburn;
• contact with certain chemicals.

However, the trigger is not always identified, and treating that factor is not enough to improve vitiligo or to prevent its progression.

The different forms of vitiligo

In 90% of cases, the disease is non-segmental: all areas of the body may be affected symmetrically. It begins with a white patch, and evolution is then unpredictable: the patch may remain stable, spread more or less quickly, or regress.

Vitiligo is said to be "active" when the disease is in a flare phase. Small signs are then present: "confetti" depigmentation, pale non-depigmented borders. These signs are often invisible to the naked eye and are only detected under ultraviolet light, with the Wood's lamp.

What are the treatment options?

Whether one or several areas are depigmented, several treatments can be considered:

• immunomodulators;
• cortisone;
• medical phototherapy (sun or UVB rays supervised by a doctor, not cosmetic UVA);
• in rare cases, a melanocyte graft (fewer than 100 patients a year in France).

The principle is clear: the more active or recent the vitiligo, the sooner it should be treated. Care pursues three goals: to halt depigmentation, to induce repigmentation, and to prevent recurrences, which occur in about 50% of cases.

Melanocyte autograft

This technique is reserved for patients with stable vitiligo (no signs visible under ultraviolet), localised (few areas), and after the failure of medical treatments. It is performed under local anaesthesia, in about three hours:

• a skin biopsy is taken from a healthy, pigmented, inconspicuous area (scalp, pubis, buttock);
• a chemical treatment separates the dermis from the epidermis to harvest only the epidermal layer;
• the resulting solution is applied to the recipient area, previously stripped of its surface layer with a laser;
• a dressing is left in place for about eight days.

The patient must then wait around nine months to assess the success of the operation.

A new molecule that reactivates melanocytes

For just over a year, a new weapon has been available: the first specific treatment for vitiligo, ruxolitinib, marketed by Incyte Biosciences under the name Opzelura. In France, the 100 g tube costs 838 euros and has been reimbursed at 65% by social security since summer 2024. One amount treats the equivalent of the surface of a hand, i.e. 1% of the body surface, for six months.

Its application is demanding: twice a day, in thin layers. It therefore remains reserved for less extensive forms. It is offered from the age of 12 to patients whose area to be treated does not exceed 10% of total body surface, i.e. around 30-40% of patients.

How does it work? The anti-JAK mechanism

Awarded the Galien 2024 prize at the end of 2024, this molecule is the first so-called anti-JAK treatment. In vitiligo, melanocytes are destroyed by certain immune cells, the T lymphocytes, via biological pathways activated by proteins called Janus kinases (JAK 1, 2, 3). Ruxolitinib inhibits precisely the action of these proteins. The result: a reduction in the aggressiveness of the lymphocytes, and melanocytes that repopulate the affected skin. The treatment is very well tolerated.

What results can be expected?

Ruxolitinib achieves on average 75% repigmentation of the face in one in two patients. But results take time: they appear only after long months of treatment, at least six and often up to twenty-four months. Moreover, the hands, feet and wrists respond less well than the face.

Other trials aim to improve these results. Current feedback suggests that combining UVB sessions with the oral intake of certain antioxidants would repigment lesions faster. These data, however, still need to be confirmed and published.

UVB and skin cancer risk

One reassuring point is worth highlighting: experience with the use of UVB has shown that the risk of developing skin cancer (melanoma and other types) is lower in patients with vitiligo than in the general population.

The Valorian analysis

Vitiligo perfectly illustrates a paradigm shift in skin medicine: a disease long considered "without a solution" now has concrete options and a first specific treatment. The essential message is twofold: vitiligo is neither contagious nor "psychological", and it is no longer true that "there is nothing to be done".

That said, a realistic view must be kept. Ruxolitinib is a major advance, but it is not a universal solution: it targets less extensive forms, requires prolonged and rigorous application, and gives better results on the face than on the extremities. Speed of care, especially in active or recent forms, remains decisive. Finally, therapeutic combinations (UVB, antioxidants) are promising but still need to be confirmed.

At Valorian, skin health is approached from a comprehensive, evidence-based perspective: recognising depigmentation early, guiding towards specialist evaluation, and avoiding the two pitfalls of vitiligo — therapeutic resignation on one side, excessive promises on the other.